Anxiety

Excerpt from:  WHY YOU DO THAT, by John B. Evans, PhD, LCSW

Anxiety^139-147 is something we all experience from time to time, and some temporary anxiety is a normal and natural response to stress, fear, and apprehension. Some stress may even be helpful in motivating us to focus on, and tackle, the source of the stress. Many normal aspects of life, such as starting school, a new job, or public speaking may give butterflies to almost anyone. But for some people, the reaction to stress may involve a more severe negative emotional reaction about what the future may hold. When anxiety is out of proportion to the perceived threat, and prevents a person from functioning normally, the anxiety is now a disorder. Anxiety may come on slowly because of some approaching event, or the stress may build up over time from multiple stressors, and this can happen to anyone at any age. If a serious level of anxiety goes untreated, it may only get worse. Fortunately, anxiety disorders are very treatable, and there are multiple treatments that have been shown to be very effective. About 30 percent of adults may be affected during their life span, and more women are diagnosed with anxiety than men. 

The symptoms of anxiety may cause or exacerbate problems in multiple areas of life, such as relationships, work, school, social activities, etc. Symptoms of anxiety may include: 

• Sleep disorders—sleeping too much or too little 
• Digestive/bowel problems 
• Fast heartrate, sweating, muscle tension ∙ Dizziness 
• Poor concentration 
• Rapid breathing 
• Nervousness, restlessness 
• Headaches or other chronic pain 
• Nightmares 
• Irrational anger/irritability 
• Suicide ideation 

     Anxiety disorders are the most common of all mental disorders, and they may occur for no obvious reason or they may be caused by a known trigger. With serious symptoms, the individual may go to the hospital out of a fear that they are coming down with a serious illness, such as a heart attack or stroke. People may try to avoid the object or event that triggers or exacerbates their anxiety, and this can make their social life, school, or job performance much more difficult. Some people suffering anxiety may be unable to enter a place of business or even leave their house. Others may seek some temporary relief in alcohol and/or drugs with the clear danger of becoming an addict. It may be necessary to treat an alcohol or drug addiction first before the accompanying anxiety/depression can be effectively addressed. 

     Anxiety frequently co-occurs with other disorders, especially depression, and this is more likely where the anxiety disorder is more severe. It is common for some level of depression to cause or contribute to some level of anxiety—or vice versa. Co-occurring anxiety and depression may result in a descending spiral of ever-increasing mental instability and may also result in insufficient treatment of the anxiety.¹⁵⁶ 183 It can be difficult to diagnose the symptoms of anxiety and depression because of overlapping symptoms such as poor concentration, sleep issues, chronic tiredness, etc. Fortunately, the same treatments, including counseling, medication, and lifestyle changes, may be effective for both disorders. 

Children can also suffer anxiety although, as with adults, it is usually a normal part of life, and they are able to cope with it in most cases. But children may also experience the more serious levels of anxiety that may become a chronic disorder, and they may exhibit symptoms such as fearfulness, irritability, sleep issues, a sense of shame, low self-esteem, etc. But anxiety in children is treatable, although I always consider the possibility that a dysfunctional or abusive home environment is the actual cause of the child’s anxiety (see chapters: Personalities in Relationships and Families; The Abusive Personality/Abusive Relationships; The Family Systems of Murray Bowen). Needless to say, anxiety in teens is to be expected with first attempts at dating, social rejection and loneliness for the less popular, school testing, body image issues, etc. Many teens experience shyness that they may eventually grow out of—or not. Teens experiencing significant anxiety may also experience some level of depression. Again, I am careful to look for family dysfunction and especially dysfunction in the parents. Children and teens may not be able to make lifestyle changes without the consent and participation of parents, and it may be the parents who need to change, which might include learning new parenting skills. Behavioral inhibition in children involving shyness and timid behavior frequently is a predictor of anxiety disorders in later life.^157 

Anxiety disorders tend to be much more common in women and girls 184 than men and boys,^156,157 and more common in those with other mental disorders, physical illnesses, unemployment, etc. 

Types of Anxiety Disorders^1,156 

NOTE: There are other anxiety disorders not included in this chapter. 

Generalized Anxiety Disorder: GAD is characterized by unjustified persistent worrying that is not due to a particular circumstance, event, object, etc. The symptoms may be both physical or psychological in nature. The worrying is sustained and unrelenting, and prevents an individual from functioning normally on a daily basis. The sufferer may have problems with irritability, nervousness and tension, concentration, tiredness, restlessness, sleep issues, gastrointestinal problems, etc. They may worry about their family relationships, financial issues, health issues, social hurdles, etc., and they may need to avoid objects or situations that can trigger their anxiety. GAD may be accompanied by other disorders including major depression, panic disorder, phobias, obsessive-compulsive disorder, etc. Approximately 50% of those with GAD will also suffer depression and this increases the suffering significantly over those experiencing either disorder alone. GAD frequently goes undiagnosed and only 20% to 32% of sufferers receive an adequate level of treatment.¹⁵⁸ 

Panic Disorder / Panic Attacks: Panic disorders involve reoccurring panic attacks where the sufferer experiences sudden feelings of intense anxiety, fear, or terror, which escalate quickly and leave the sufferer with feelings of extreme psychological and physical discomfort. The individual may have a sense of losing control, feelings of unreality or being detached from oneself, or feelings of doom or imminent death. Physical symptoms may include rapid heart rate, chest pain, sweating, nausea, stomach pain, chills, hot flashes, numbness, shortness of breath or choking, trembling, nausea, headaches, or dizziness. Panic attacks usually peak in about 10 minutes and last for about 30 to 45 minutes. Approximately two-thirds of panic disorder sufferers also experience agoraphobia. 

Panic attacks may appear at any time and for no apparent reason, or they may be triggered by specific objects, places, or events, and the individual may go to extreme lengths to avoid these circumstances. They may occur anywhere, whether at home, the grocery store, a party, etc. Some people may only experience one or a few panic attacks, which then just go away, while others may experience recurrent attacks over longer periods of time. Some people may be more susceptible to the onset of panic attacks due to genetics or their level of stress, or they may have a temperament or personality that tends towards negative emotional reactions. Research has suggested that the body’s natural “fight-or-flight†response may play a role in panic attacks. It is easy to see how the symptoms listed above might be present if an assault or being trapped in a housefire seems imminent. Although panic attacks are not life threatening, when the attack subsides, the individual may then experience anxiety and worry about the next attack. 

 Fortunately, as with other anxiety disorders, panic attacks may respond very well to medications, talk therapy, lifestyle changes, or a combination of treatments, and panic attacks may get worse without treatment. Techniques for an immediate response to a panic attack include: 

1: Deep breathing/meditation techniques can be very effective at reducing the stress response. In particular, practicing progressive muscle relaxation in conjunction with deep breathing techniques can be especially beneficial. There are many sources on video and online that teach deep breathing/meditation and progressive relaxation techniques. 

2: Finding a quiet place that reduces the amount of stimulation can be very helpful, especially if combined with deep breathing/meditation and progressive relaxation techniques. 

3: There is no need to struggle to make it go away. A passive attitude is more effective in the moment. You can accurately tell yourself the attack will pass and that, with available treatments, panic attacks can be eliminated from your life completely. 

4: Regular aerobic exercise such as brisk walking, bicycling, aerobics classes, jogging, swimming, etc., can be very effective at reducing anxiety, and these kinds of exercises have been shown to have excellent antidepressant effects as well. Brisk walking is an exceptional form of exercise in that it can begin right outside your front door or happen in front of a TV with a treadmill. 

Phobias: When someone has an extreme aversion to, or fear of, something that is generally harmless, this is referred to as a specific phobia. The sufferer generally knows that their fears of bugs, snakes, spiders, dogs, airplanes, heights, the sight of blood, getting shots, dentists, etc., are baseless and irrational, but their fears may remain for years or a lifetime. Their behavior may appear odd when they go to extremes to avoid the feared object or event, and they may suffer intense anxiety when the feared object or event cannot be avoided. 

Agoraphobia: Agoraphobia is the fear of any situation or environment that might be difficult to escape from, including situations that might cause feelings of embarrassment, feeling trapped where help might not be available, or just feeling helpless.¹⁵⁶ Examples include being in crowds or standing in lines, enclosed spaces, being alone in public, or using public transportation. Some sufferers may force themselves to endure the intense anxiety and fear if the situation cannot be avoided. Others may isolate themselves in their home unless they have a companion with them. 

Social Anxiety Disorder / Social Phobia / Shyness:¹⁶¹ Social Anxiety Disorder or Social Phobia, that is, shyness, involves a persistent and unreasonable fear of being negatively evaluated or criticized by other people in social situations or performance situations, and can be debilitating in its effects.¹⁵⁶ Shy people experience emotional overreactions such as nervousness, embarrassment, shame, submissiveness, depression, etc., and the more generalized the shyness has become to multiple areas of life, the more problems the shy person will experience. Some shy individuals may avoid most social situations, as well as school or work events, and some may never get married. They may suffer financial problems because of missed employment opportunities or absenteeism, and some shy people turn to alcohol or drugs to help allay their fears or just numb the pain of isolation and loneliness. Studies have shown that many problem drinkers are shy.⁸⁰ Studies of shyness have found this disorder to be the most common of all anxiety disorders, and the most common psychiatric disorder after major depression and the abuse of alcohol. 

Over the life span, between 7% and 13% of individuals in Western 188 countries will experience a moderate to severe level of shyness, and most people with shyness go untreated since there is little awareness of the symptoms among the general population. Between 80 percent and 90 percent of people diagnosed with a serious level of shyness also suffer from at least one other disorder, with up to half of those suffering from major depression. Other disorders commonly found with more severe levels of shyness include eating disorders, agoraphobia, obsessive- compulsive disorders, post-traumatic stress disorder (PTSD), and bipolar disorder. Individuals with more severe shyness combined with another clinical disorder will typically suffer even greater dysfunction and a further reduced quality of life.^92 

The contributing factors to shyness are complex and may include genetic/temperament factors, shy thinking, inadequate or abusive parenting, a chaotic family environment, negative life events, etc. In cases where there is a genetic predisposition for shyness, it may take less stress to bring shyness to fruition. Negative parenting associated with shyness includes control, rejection, neglect, a lack of warmth and affection, being overly protective, parent anxiety, insensitivity, restrictiveness or rigidity, isolation, criticism, shaming, and an over- concern with the opinions of others. Parental over-control prevents a child from developing the confidence that comes from exploring the environment and learning new skills on his own outside of parental instruction. Repeated parental rejection will make the child insecure in his sense of attachment, and children with insecure attachment are more likely to experience anxiety disorders. The level of anxiety in the parents may influence the level of anxiety in the child, and shy parents are more likely to produce shy children. Helping a shy child must include interventions that help the parents with their own problems, including their marital problems, as well as helping the parents understand the emotional needs of their child along with some instruction in parenting skills. Of course, the child’s natural temperament may influence the parent’s style of parenting. 

Traumatic/stressful events, such as divorce, the death of a family member, separation from a family member, changing schools, having a new step-parent, teasing or being bullied, family violence, sexual or physical abuse, childhood illness, etc., are other risk factors for developing shyness or other anxiety disorders. And gender roles may also play a role in shyness since studies report more shyness among women than men. The most severe form of shyness is avoidant personality disorder (see chapter: The Shy Personality). 

Dependent Personality Disorder: The dependent personality involves feelings of anxiety and helplessness such that the individual feels incapable of caring for him/herself and needs help with even the most basic decisions such as where to go to school, what job to apply for, what clothes to wear, etc. (see chapter: The Dependent Personality). 

Separation Anxiety Disorder: Separation anxiety disorder involves an extreme fear of being separated from those to whom the sufferer feels close and attached. These individuals may experience a serious level of distress at just the thought of being separated from their loved ones, and may worry about unexpected events that might require some separation. They may also worry that those they are close to might be harmed in some way. Separation anxiety disorder in children may simply go away as the child enters adolescence. 

Obsessive-Compulsive Disorders: There are two distinct obsessive-compulsive personalities. One personality is called obsessive-compulsive disorder, or OCD, and the other is the much more common obsessive-compulsive personality disorder, or OCPD. For the OCPD, the emphasis is on perfectionism, orderliness, the need for control, the need to be right, avoiding humiliation, and they may be quick to anger. For the OCD, the emphasis is on obsessive thoughts that produce anxiety, which are then followed by mental or behavioral rituals designed to alleviate the anxiety (See chapter: The Obsessive- Compulsive Personalities). 

Posttraumatic Stress Disorder (PTSD):^146,156 Some people who have witnessed or been involved in a traumatic event, such as war, serious accident, assault, rape, natural disasters, abuse, etc., may suffer the symptoms of PTSD for an extended period of time, even years, after the traumatic event. They repeatedly re-experience the event in their mind as if it were happening all over again, and may experience feelings of helplessness or fear that result in repeating episodes of anger, depression, nightmares, flashbacks, or recurring thoughts that they are unable to get rid of. They may have strong reactions to reminders of the event, such as a loud noise like an auto backfire. I have had several clients who worked in positions such as emergency room nurses, ambulance medics, police officers, etc., where repeated contact with accident or assault victims eventually left them with clear symptoms of PTSD. Victims of spousal abuse or child abuse may experience the symptoms of PTSD years after leaving, or being removed from, the abusive environment. The sufferer may experience negative changes in mood or thoughts, and may experience sleep disturbances and/or an aroused hypervigilant state. There may be attempts to avoid stimuli 191 associated with the traumatic experience. To be diagnosed with PTSD, the symptoms must last for more than a month although the onset of symptoms may not appear until long after the traumatic event. PTSD may co-occur with other mental disorders such as depression, problems with memory, or alcohol/drug addiction. According to the American Psychiatric Association, the symptoms of PTSD fall into four categories:¹⁴⁶ 

1: Intrusive thoughts: flashbacks, dreams, or memories that will not go away. 

2: Avoiding reminders of the traumatic event including places, people, or similar events that may trigger their symptoms. It is common for war survivors to never talk about their war experiences or refuse to watch war-based movies for the rest of their lives. 

3: Negative thoughts and feelings including negative self-talk such as, “I’m a loser,†etc., along with negative feelings of shame, fear, guilt, etc. There may also be feelings of isolation and separation from others. Some PTSD sufferers may get little joy from activities they used to look forward to. 

4: Arousal and reactive symptoms including mood shifts such as irritability/anger, acting out in self-destructive ways, problems with concentration or sleep, or being startled when surprised by the unexpected, such as a loud noise. 

Causes of Anxiety 

While the exact causes of anxiety are unknown, multiple causes may be involved including psychological, genetic, or environmental factors. Risk factors known to increase the likelihood of developing an anxiety disorder include:^144 

Trauma: People who have experienced some level of abuse or trauma, or have witnessed others being abused or traumatized, may develop an anxiety disorder at some point in their life. This can happen to children as well as adults, but with children, the anxiety disorder may be more severe and enduring. 

Multiple Stressors: Multiple stressors over time, which, individually, may be less significant, but together may result in considerable anxiety. For example, an individual experiencing marital and/or family discord, doesn’t get along with his boss, and has financial problems caused by poor health may develop an anxiety disorder. 

Personality or Mood Disorder: Individuals with some personality types, such as the obsessive-compulsive, shy, borderline, dependent, or paranoid personalities, or suffer a mood disorder such as depression or bipolar, may experience some level of stress and anxiety simply because of how they naturally view, and react to, themselves, other people, events, etc. 

Blood Relatives: Anxiety disorders can run in families suggesting a genetic connection. 

Drugs/Alcohol: Drug/alcohol use, abuse, or withdrawal can increase the likelihood of some level of anxiety, or worsen anxiety that is already present. 

Medical Condition: Anxiety disorders may be the first indication of an underlying medical condition, and a physical exam may be necessary to rule out any possible underlying causes. The known physical causes of anxiety include: 

• Heart disease 
• Diabetes 
• Thyroid problems 
• Respiratory problems such as chronic obstructive pulmonary disease or asthma 
• Alcohol/drug misuse or withdrawal 
• Chronic pain or irritable bowel syndrome 
• Rare tumors that produce certain fight-or-flight hormones 

Treatment 

Anxiety due to circumstances or events may resolve itself over time. But with more chronic and severe anxiety, psychological or medication interventions may be very helpful. But many people who might benefit from treatment do not get it since anxiety sufferers may not even know they have a diagnosable disorder, and so may not seek treatment. Studies have shown that anxiety frequently goes undiagnosed because many patients do not discuss emotional issues with their doctors fearing the distress or embarrassment involved, or believing the doctor could not help anyway. Other obstacles might include the cost, or simply not knowing where to get the help they need. In some cases, the patient may recognize their depression without recognizing the co-occurring anxiety.¹⁵⁶ This is unfortunate since there are multiple treatments that have been shown to be effective in treating the symptoms of anxiety. Many psychotherapy treatments, including cognitive behavioral therapy (CBT), have extensive research demonstrating their effectiveness,¹⁵⁶ and medications have also been shown to be effective in helping sufferers gain significant relief. CBT helps sufferers learn new ways of thinking and behaving, which allows them to react differently to stressful or feared objects and situations. While some in the media suggest an over-medicalization of people dealing with life issues and difficulties, including anxiety, shyness, depression, etc., the greater problem appears to be one of under-diagnosis and insufficient treatment. A part of this may be sufferers’ fear of becoming dependent on the medication or having serious side effects.¹⁵⁶ These medications are not addictive, and I have found most people who stick with the trial-and- error process of finding the right medication for them will usually find considerable relief from the modern medications available today. 

Stress management techniques, such as deep breathing/meditation techniques including progressive muscle relaxation, can be very helpful at reducing the symptoms of anxiety. Deep breathing and progressive muscle relaxation are sometimes used in combination with exposure therapy where the individual is gradually exposed to the feared object or situation while using relaxation techniques to help avoid emotional overreactions. Techniques for dealing with anxiety can be learned in individual counseling or group therapy settings, and multiple book and online sources are available. I am a big believer in support groups where an individual can meet other people with similar problems, which may help avoid the sense of being alone as well as allow the individual to learn from the experiences of others. And, as always, becoming educated about the particular problem/symptoms an individual is experiencing may be immensely helpful at increasing the individual’s self-awareness, which helps them gain control over their symptoms and eliminate negative self-talk. 

For some people, lifestyle changes may be all that is necessary to obtain some relief, including: 

• Changing their job 
• Finding new friends 
• Ending an abusive marriage (see chapter: The Abusive Personality/Abusive Relationships) 
• Beginning an exercise regimen 
• Cutting down or eliminating alcohol or caffeine 
• Improved sleep regimen 
• Improved diet 
• Practicing meditation/deep breathing/progressive muscle relaxation 
• Quitting smoking 

Aerobic exercises which speed up the heart are known for their antianxiety and antidepressant effects. Many people experiencing the symptoms of anxiety and/or depression find considerable relief with some form of exercise such as brisk walking, jogging, bicycling, swimming, aerobics classes, various machines such as treadmills, stair- step or elliptical machines, etc. I encourage all of my clients suffering any level of anxiety or depression to stay active on a daily basis since the beneficial effects of exercise are temporary, so a daily regimen is essential. A trial-and-error process of trying several forms of exercise may help you find the most enjoyable exercise for you. For people who stick with it, their exercise routine frequently becomes their favorite part of the day.      

Consultation with a doctor or psychiatrist will help determine if the use of medication is warranted. I have seen many people experience considerable relief from the many effective medications now available, although a trial-and-error period may be necessary where different medications are tried in order to find the most effective medication for a given individual. For many people, the best results occur with some combination of medication, talk therapy, and lifestyle changes including exercise. When anxiety co-occurs with depression, antidepressant medications may offer relief from both the anxiety and the depression.^156